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West Virginia Form Center -

Type & Print Forms - programmed for direct type and print functionality.

Each form may be downloaded in Adobe Acrobat format. Download the form by clicking on the form number below.
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OIC-WC-2.pdf Employers' Report of Occupational Injury or Disease
OIC-WC-1.pdf Employees' and Physicians' Report of Occupational Injury or Disease
OIC-WC-1HL.pdf Employees' and Physicians' Report of Occupational Hearing Loss
OIC-WC-1OP.pdf Employees' Report of Occupational Pneumoconiosis
OIC-WC-20P.pdf Employer's Report of Occupational Pneumoconiosis
OIC-WC-30P.pdf Physician's Report of Occupational Pneumoconiosis - Includes ILO Form
OIC-WC-201.pdf Application for Fatal Dependents' Benefits
OIC-WC-202.pdf Application for 104 Weeks Dependents' Benefits
claims-allocation-information.pdf Notification Regarding Claims Allocation
wc_complaint_form.pdf Workers' Compensation Complaint Form
exemption-application.pdf Application for Exemption from WV Workers' Compensation Coverage
microfiche.pdf Request for File Record Copies
citizen_report.pdf Suspected Insurance Fraud Citizen Reporting Form
fraud-company-contact-form.pdf Insurance Company Fraud Contact Form
fraud_uniform_form.pdf Uniform Suspected Insurance Fraud Reporting
occ-lung-exam.pdf Carrier's Request for Occupational Lung Center Examination
rsr1.pdf Request for Settlement Review
complaint-form.pdf Workers' Self-Insurance Compensation Complaint Form
term-cov.pdf Termination of Coverage
travel-expense-notice.pdf Payment for Travel Expenses Notice
UninsuredFundApplication.pdf Employee's Report of Occupational Injury and Proof of Employment
Direct-Deposit-Form.pdf Workers Compensation Direct Deposit Form
Notice.pdf POSTER - Generic Notice to Employees poster.
WVBrochure.pdf Brochure - Understanding the West Virginia Workers' Compensation Claims Process
Low_Back_Examination.pdf Low Back Examination
Perm_Tot_Dia_Rev.pdf Carrier/Self-Insured/TPA Request for Permanent Total Disability Review
origxray.pdf Request for Original X-Rays
xrayrequest.pdf Request for X Rays